GW1-2021-05389_Well Construction - GW1_20211013

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WELL CONSTRUCTION RECORD For livemnl Use ONLY:
•R s ftm can be ened.foaslmgk or mu1tiyir was
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t.Well Contractor Information: ---
Stefan Smith R M. tiri"Ir'tOY
'Mch cants olor Iva" �.201� n, ft.
3576A J (, R. a:indNkatidt
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NCWeHCORMWtOfCMiificitiouNumbcr f�egjt�9 13 OtFfRIt irn. :oR' nea6le::.
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O' pCG +Qn OM To nrAWTF.R ,ss MAW.RTAL
SAHDACCO Inc v\. SSG' 0 (L15 k 1° in. SCH-40 PVC
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C-vmw`Nam 16.1"t3NEit: 1VGffR:3i?BPIGr eai�ereiet 4iio
FROMTo I DIWETRR I TffWkNTM I MATrRJAL
2,Well Canhtraction Permit#: 50000079
I W 4dl aw ilirUNO,Neu " os ti o.Cmmty,soar,vado re.lf*uc l sir:f
3.Wd1 ttsctcfnxkRdivaek 7S
Water Supph,Well: FROM I TO I DrAMRMR I St,OT W ITrtt(aCYFS$ aaaTFarrAr;.
C)Agftltmal t3municipamblic 15 ft. 25 ft. 1° 406 .010 SCR
-40 PVC
❑Geothemrai(Heating Boling Supply) OResidential Water Supply(single) ft. to
01ndlishialf0olnntemial OResidential Water Supply(sluTed) 8 ttROtt3
FROM TO SitATERtAL E"TPLACFMP.1'T Mt?RtOn/CAMOUNT
Olitigmion ft. f!
Non-WaterSupnlywell: (L ft,
mmonb n ❑Re¢rrr
tnjectlon fL tt:
QAquifcr Rcchaxge Brea nidwatcr Retnodiarion A)t
QAgtriler Stonige and Recmtiriy D5aliniiy Bam icr w to RrAt, t�Mrinc�trrrr vT i n
13 ft. 25 ik SAND #2
Q iferTess Q5tonmsaterDntin3gc
DExpciiincrttal Tmimolog 13Subsidc cc Conitiol
10.,A RANG,r0 k."dillftrmf93kerts4f isicr
t7Geottiemal(Closed 14op) ❑Tracer vaoxf I TO armCRtPifONrtot.r,t+eri suazttc&ape,ffm fteh.
OGeodw=1(HeafintrAoling Retunt) 00diet(ambin under021 Remaris) 1 0 fL 22 (L silt
22 ft. 25 M Sandy 'silt
4.Date WOW Completed: 8/31/21 Wdltf)#B-7
n. tL
So.Well L WAtion: IL FL
Shell Oil Products, US (L ft.
F®cilegrbnnerNnmc Fmilk iV#Orapplimble)
tt, tl.
101 W. Woodlawn Rd., Charlotte, NC, 28217 {� n
Pltrai=1 Address.i`•it}..M4Zip 21 It
Mecklenburg 16903203 Temp well for groundwater grab sample.
Caatoy ft ma 16toirka""140-(M)
.r+b.Latitadcand t iingitode in dcgivesimirrrtteshAectinds or decimal degmem. 2L CerFircatinn•
{stabs field,one IMong is sidntkm)
35.178820 b* 80.883975 W 9/28/2021
5isi of sod Wail Canuactor Datc
6.IS(are)the+well(s): OPermanent or OTmiporary By 00n8101it foray1 r he rha thr url!{.tj war(rretr)as;arrnnied im atrom nee
idth 15A ATAC OTC.91 M or 1 SA NCAC f12C.L1M Well Cemslrrft,* r Stantiff4is god abet a
7.Is this a impair to an eAsOng well: OVes or ONo ►,r styli 4m7rrr.
If AIs&o rawly,fill 4w shwa uvr11 coatr+rlcrfan info ror&m and rxptoin the,moire of fAr
r4ryvirrnederb2l rmorks srviim or m At bard of this forte: 23.Site dlagrain or ad ill tional weft details:
You tuay use the back of this page Jo,pm%ide additional uvil site details:or well
8.l tim�er of wells c>,nstrttctrd: 1 constmedon details. You may,also attaeh additlmmt pages if nocessaty.
for M"101 ein/rct 10r tan-1owr ngrpdr writ ON, "*h Me WMrW,shvrrtlott.vaa'M
seieonitaarfMM stutri —rALINSTEICTI n
9.Totai fwdt depth below find stii.&M 25 {R} 24s. Por All Well Stib Trit Ws lbnn within 30 ds}%,of completion of welt
Formiilllpirwrttriifr oil de s#dieierrivlexmiptr•3@200*asd2@lnlly consttnctionto the fgthming;
10.Static outer Intl below top ofrasing� 19 (R,) Division of Water Resources,Information Processing Unk.
lfl4vnor byes Is abover dos ere'4" 1617 Mail Seniee Center,Rdeligh,NC 276'89-1617
114'Borehole diameter 2.25 24b.&r InWslit Wells ONLY: In addition to sending the fatm to the-address in
24aabove.also phmit a copy of this form within 30 days of completion of well
12.Well Construction method:DPT constnrction to the tbllovVhig:
(Lt.sine.rater);cibleq tined push ck_)
Division of Water Resmtrces.V64erground Injection Control Program,
FOR WATER SUPPI Y WELLS ONLY 1636 M811 Senice Center,Raleigh,NC 2769946M
13a Vidd(gpm) Method of tat: 74c.For Water Salrpf�g�&Ipjoaclrin Wells:
Also submit one cop) of this fonh tvidiin'30 days of cotugtletion of
13b.Disinfecdon type: Amount: wC11 constmiction to the comet tie4 hh dcpadment of the warmly where
constructed.
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FameGW-t NonhCarotinsDq=tmrntofEertmnmcntxx1bbt rilResotaocs-lSitizsbaafa'aterR(5dnrt6 Revised Aug=2013